Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content ++ Metastasis (colon, breast, neuroendocrine).Hepatocellular carcinoma.Cholangiocarcinoma.Hepatoblastoma.Gallbladder carcinoma.Hepatic sarcoma.Adenoma.Biliary cystadenoma.Symptomatic hemangioma or focal nodular hyperplasia.Hepatic tumor of unknown etiology. ++ Distant metastatic disease for primary liver tumors.Presence of extrahepatic metastases for metastatic lesions (relative).Severe medical comorbidity.Inability to achieve negative margins.Insufficient estimated liver remnant following resection.Significant cirrhosis or portal hypertension. +++ Expected Benefits ++ Surgical treatment of primary and metastatic hepatic malignancies.Treatment of symptomatic benign hepatic mass. +++ Potential Risks ++ Bleeding requiring reoperation or transfusion.Infection or abscess.Embolic events.Bile leak or stricture.Tumor recurrence.Possibility of unexpected findings intraoperatively.Need for additional tests or procedures.Hepatic dysfunction or failure.Death. ++ Intraoperative ultrasound equipment.Self-retaining retractor (eg, Omni or Thompson).Electrocautery, Cavitron Ultrasonic Surgical Aspirator (CUSA), Hydrojet, automatic clip applier, and possibly Tissue Link, LigaSure, or SonoSurg devices, depending on surgeon preference. ++ Nothing by mouth the evening before surgery.Preoperative antibiotics.Adequate intravenous access (at least two > 16G intravenous lines and central venous pressure [CVP] line at the surgeon's discretion).Foley catheter.Orogastric tube decompression.Anesthesiology consultation and coordination. +++ Patient Positioning ++ The patient should be supine with arms extended. ++ Figure 14–1: Familiarity with hepatic segmental anatomy is important (Couinaud) to allow for resection planning along with intraoperative ultrasound.Figure 14–2A, B: Important vascular landmarks for planning of anatomic resections showing hepatic veins and main portal venous branches. Planes of transection for major hepatectomies are as follows: Right lobectomy, right trisegmentectomy (extended right lobectomy) (Figure 14–2A).Left lobectomy, left trisegmentectomy (extended left lobectomy), and left lateral segmentectomy (Figure 14–2B).Figure 14–3: Right hepatic lobectomy or extended right hepatic lobectomy. Identification and isolation of the right hepatic artery and right hepatic duct.Figure 14–4: Right hepatic lobectomy or extended right hepatic lobectomy. Identification of right portal vein. Biliary and vascular structures can be divided before hepatic transection or after, depending on surgeon preference.The portal vein should be oversewn with Prolene suture or secured with a vascular stapler.Figure 14–5: Right hepatic lobectomy or extended right hepatic lobectomy. Additional mobilization of the right hepatic lobe is performed by reflecting it lateral to medial.Caudate hepatic vein branches as well as accessory right hepatic venous branches are ligated.The right hepatic vein can be divided before or during parenchymal dissection and oversewn with Prolene or secured with a vascular stapler.Figure 14–6: Right hepatic lobectomy. Parenchymal transection is performed by using vascular demarcation (if inflow is divided) or along the transection plane as detailed in Figure 14–2 (marked by ultrasound).Transection is performed under intermittent inflow occlusion and maintaining a low CVP (3–7 mm Hg). Manual compression can also minimize blood loss from small hepatic veins.Transection is initiated with electrocautery followed by CUSA or Hydrojet dissection to identify vascular or ... Your Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Download the Access App: iOS | Android Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.